LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH

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1 PLEASE PRINT PATIENT INFORMATION TODAY S DATE: LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP HOME CELL OCCUPATION EMPLOYER/SCHOOL WORK SOCIAL SECURITY NO SEX: M / F DATE OF BIRTH MARITAL STATUS: S / M / D / W EMERGENCY CONTACT (Name) ONE_ RELATIONSHIP INSURANCE INFORMATION RESPONSIBLE PARTY (If under 19 years) ADDRESS APT CITY STATE ZIP P R I M A R Y I N S UR AN CE COV ER AGE INSURANCE COMPANY SUBSCRIBER NAME SS# DATE OF BIRTH RELATIONSHIP TO PATIENT POLICY ID# GROUP # S ECON DAR Y I N S UR AN CE COV ER AGE INSURANCE COMPANY SUBSCRIBER NAME SS# DATE OF BIRTH RELATIONSHIP TO PATIENT POLICY ID# GROUP # Assignment of insurance benefits, release of information and authorization for treatment, responsibility for payment, and medical release: I authorize PT Solutions to provide physical therapy treatment, tests and procedures considered advisable by my physician. I, the undersigned, do hereby expressly guarantee payment in full of any and all claims and charges in consideration for medical services rendered by PT Solutions. I hereby authorize and demand the assignment of my basic medical, major medical, auto medical, third party medical or any other medical benefits that my apply, herein specified and otherwise payable to me, directly to PT Solutions. I authorize PT Solutions to release medical information acquired in the course of my treatment and examination to my insurance company and to my physicians. If for any reason the account should become delinquent, I agree to pay all rebilling charges, costs related to collection efforts, and reasonable legal fees. I have read and understand the policies as mentioned above. SIGNATURE OF PATIENT, GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE SIGNED Pt Info Revised 11/10/04, 10/22/08, 7/10/12

2 CURRENT INJURY / DISORDER INFORMATION REFERRING DOCTOR: TYPE OF INJURY/DISORDER/CONCERN IS THIS INJURY RELATED TO: WORK / AUTO / SCHOOL SPORTS / RECREATIONAL SPORTS / OTHER PLEASE DESCRIBE HOW AND WHEN INJURY/DISORDER OCCURRED PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PAIN/SYMPTOMS: MY PAIN IS WORSE IN THE: MORNING / EVENING / SAME / FLUCTUATES / IN CONSTANT PAIN PLEASE LIST ANY ACTIVITIES THAT INCREASE YOUR PAIN/SYMPTOMS: PLEASE LIST ANY ACTIVITIES THAT DECREASE YOUR PAIN/SYMPTOMS? WHAT IS YOUR LEVEL OF PAIN RIGHT NOW? NO PAIN WORST PAIN EVER ****ARE YOU CURRENTLY RECEIVING OR HAVE YOU RECEIVED HOME HEALTH CARE WITHIN PAST 60 DAYS? YES/NO If yes, what dates did you receive services? COMPANY NAME? *****HAVE YOU RECEIVED YSICAL THERAPY WITHIN THE CALENDAR YEAR? YES/NO HOW DID YOU HEAR ABOUT PT SOLUTIONS? Physician Web site/advertisement Friend/Family/Co-worker Insurance company Coach/ Athletic Trainer Other Who may we thank for referring you? Describe your pain. Use all that apply. Sharp Dull Tingling Tight Shooting Throbbing Numb Pulling Burning Ache Heavy Stabbing Describe the behavior of your symptoms. Use all that apply. Constant (Never goes away) Intermittent (relieved with some positions or rest) Occasionally (Daily or less frequent) Infrequently (once a week or month) Previously (No longer present) Variable (Sometimes worse than other times) CIRCLE AREA OF PAIN ON THE DIAGRAM PRIVACY NOTICE I, the undersigned, do hereby acknowledge that I have been made aware of the legal duties and policies and procedures of PT Solutions regarding the protection of my personal health information. I understand and agree that, unless I request otherwise in writing, PT Solutions will communicate with me via phone, fax, and and will state the company name when leaving messages for me via any of these means. Additionally, I have been informed of the company name and I am aware of how I may contact the Privacy Officer should I have questions or comments regarding the privacy practices of PT Solutions. SIGNATURE OF PATIENT, GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE SIGNED

3 MEDICAL HISTORY SCREENING FORM To best serve your needs and understand your medical condition please complete the following. Thank you for your patience. Please circle yes or no and list where appropriate: Patient Family Have you or any immediate family member ever been told you have or are you aware of symptoms related to.. Cancer? Diabetes? High blood pressure? Heart disease/heart attack? Angina/Chest pain? Stroke? Osteoporosis or Osteopenia? Osteoarthritis? Rheumatoid arthritis? Other? _ Do you have a history of: Allergies/Asthma? Are you under stress? Headaches? Are your symptoms getting Worse The same Improve Bronchitis? How are you able to sleep? Fine Moderate Medicate Kidney disease/problems? Do you have a problem with Vision Hearing Speech Rheumatic fever? How do you learn best? Seeing Doing Hearing Ulcers? Do you drink alcohol? Yes _/week No Sexually transmitted disease? Do you or have you smoked? Yes _Packs/Day Yrs No Seizures? Describe your activity level Minimal Moderate High Nervous disorders? Date of last medical examination / / Hernia? List of Medications you Metal implants? currently use: Pacemaker? Dizziness/Balance problems? Are you pregnant? Sensitive to heat/ice? Are you depressed? In the past 3 months, have you had or did you experience: A change in your health? Nausea/vomiting? Fever/chills/sweats? Unexplained weight change? Numbness or tingling? Changes in appetite? Difficulty swallowing? Changes in bowel or bladder dysfunction? Shortness of breath? Dizziness? Upper respiratory infection? Urinary tract infection? Patient Signature: Date of Completion:

4 Welcome to PT Solutions! Please take a minute to review our financial policies, which are designed to clarify your billing and payment questions and assist us in serving you. For your convenience, we will verify your insurance benefits and make our best effort to inform you of any services that your insurance may not cover. We will file for you all insurance claims for services rendered, and make every effort to obtain reimbursement. However, you are ultimately responsible for insuring we are appropriately reimbursed for the charges incurred during the course of your treatment. Any unmet deductible and co-insurance amounts, according to your insurance benefits, will be collected at the time of service. Should your insurance company decline to pay for rendered services or should there be any remaining balance that is your responsibility, our billing office will forward a statement to you. We will gladly accept cash, checks, and credit cards for your payment. If a check for payment is returned from our bank there will be a $30 returned check fee added to your account. This fee will need to be paid at your next visit. This could result in no longer being able to accept a check for payment. At PT Solutions, we are dedicated to providing the best possible service for you. If you have any questions or concerns, please feel free to contact our Office Manager. Please note the following policies pertaining more specifically to your insurance coverage. Private and Commercial Insurance Billing and Payment Policies: Physical Therapy is usually covered under the major medical portion of most commercial insurance policies. Therefore, your insurance carrier may hold you responsible for a major medical deductible and coinsurance portion of the services you receive. We will verify all benefits and inform you of those services your insurance carrier may not cover. Based on the information provided by your insurance company during insurance verification, we will estimate the portion of charges for which you should be responsible, taking into consideration coordination of benefits, should you have coverage under multiple insurance policies. If your insurance company requires prior authorization or precertification for treatment, we ask that you play a proactive part in insurance that all visits are properly pre-approved. In the event that your insurance company considers our services to be out of network, we will make every effort to accommodate their requirements and will work with you to ensure that you receive your necessary care. Your insurance benefits are: Deductible (Unmet portion): $ Copay: $ per visit Coinsurance: % per visit

5 Medicare Billing and Payment Policies: Medicare covers our services under the Part B, major medical portion of your policy. Therefore, if you do not have a supplemental insurance policy, you will be responsible for satisfying your deductible and 20% of all Medicare allowed fees and we ask that you pay any applicable deductible and co-insurance amounts at each visit. We will inform you of any charges which we anticipate Medicare may not cover and ask that you pay for these services when rendered Worker s Compensation Requirements and Payment Policies: It is ultimately your responsibility to adhere to all conditions and policies set forth by your employer s workers compensation carrier to insure they will pay for our services, including but not limited to utilizing specific approved care providers and obtaining prior authorization for treatment. Most workers compensation carriers require prior approval/precertification before services are provided. We ask that you confirm that each visit has been approved prior to your visit. In the event that your employer denies responsibility for your injury or you do not adhere to your employer s guidelines, you will be responsible for the charges that are incurred during the duration of your treatment. Please notify us immediately if it is determined that your employer will not be covering your injury, so we can discuss alternatives, such as billing your private health insurance. Our office is willing to work with you and coordinate with your health insurance company to insure that you receive the maximum benefits, as outlined in your policy. Auto Insurance/ Accident Billing and Payment Policies: If your injury is a result of an auto or other accident for which a third party may be liable, the insurance for the other party likely will not agree to pay us until you have achieved your maximum recovery sign documentation releasing the third party from any further liability. Therefore, we cannot wait for this reimbursement. We will bill your personal auto or liability insurance, if indicated, as your primary payer, and we will then bill your personal health insurance. You will be asked to pay any deductibles and coinsurance portion at the time of service. If you retain an attorney to assist with reimbursement for this injury, please forward your attorney s name and phone number to us as soon as possible. If you have any questions of concerns about our billing and payment policies, please feel free to ask our office staff. We are here to assist. I have read and understand these billing and payment policies and my responsibilities in order to ensure appropriate reimbursement for the services I receive. Signature Date

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